FNP: Heart Failure

Pregabalin and gabapentin can cause peripheral edema, which is particularly dangerous for patients with underlying heart failure. Because this patient is experiencing an acute exacerbation of heart failure symptoms, the medication must be stopped. However, gabapentinoids must be tapered gradually over at least one week to prevent withdrawal symptoms like agitation, anxiety, and seizures. Option A is incorrect because abrupt discontinuation risks precipitating withdrawal seizures. Option B is incorrect because treating an adverse drug effect with another medication while continuing the offending agent is inappropriate, especially in decompensated heart failure. Option D is incorrect because gabapentin shares the exact same risk for causing peripheral edema and would not resolve the patient's swelling.

The patient has an acute, severely painful flare isolated to a single joint, complicated by heart failure with reduced ejection fraction. Performing an intra-articular corticosteroid knee joint injection delivers rapid, potent localized relief while minimizing systemic absorption. Recommending scheduled oral naproxen is strictly contraindicated because NSAIDs cause sodium and water retention, which can easily exacerbate his heart failure. Prescribing a short course of oral dexamethasone exposes him to unnecessary systemic glucocorticoid effects when targeted local therapy is available. Initiating daily oral colchicine is indicated for acute gout flares, not for osteoarthritis exacerbations.

Caregiver exhaustion is a common and critical issue in home hospice. The Medicare hospice benefit specifically includes respite care, which allows the patient to be temporarily admitted to an inpatient facility for up to five days to provide relief and prevent caregiver burnout. Option A is incorrect because nursing facility placement does not require revoking hospice; hospice can be provided in a facility, but temporary respite should be tried first. Option C inappropriately medicalizes the spouse's situational exhaustion without addressing the root cause of the physical burden. Option D is incorrect because discontinuing hospice would remove the essential end-of-life support the patient currently requires.

This patient is experiencing a high symptom burden but still wants to continue life-prolonging therapies like milrinone. Palliative care is the best choice because it focuses on symptom management and quality of life while allowing the patient to receive concurrent life-prolonging therapies. Option A is incorrect because hospice requires the patient to forgo curative or life-prolonging treatments for their terminal diagnosis. Option C is inappropriate because the patient's goals of care explicitly include continuing the infusion, and forcing discontinuation violates patient autonomy. Option D ignores the primary need for specialized symptom management and goals of care alignment.

In patients with atrial fibrillation and heart failure with reduced ejection fraction, beta-blockers like metoprolol succinate are the preferred agents for rate control because they provide significant mortality benefits. Non-dihydropyridine calcium channel blockers, such as verapamil and diltiazem, are strictly contraindicated in this population due to their negative inotropic effects, which can significantly worsen heart failure symptoms. Amlodipine is a dihydropyridine calcium channel blocker; while it is safe to use in heart failure, it does not provide atrioventricular nodal blockade and therefore will not control her elevated heart rate.